INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 26-28, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, The Program for Offenders, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
The facility failed to document that the project director completed at least 12 clock hours of training for the 2018 training year.
Personnel and training records were reviewed on June 26-28, 2019. The project director, employee #1, had 6 hours of training documented for the January - December 2018 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff including the Executive Director will obtain the required number of trainings per staff requirements. In this case, the Executive Director will receive at least 12 hours of training each year. This will be reviewed by the Training Coordinator halfway through each calendar year to ensure that prior to monitoring, all staff have obtained the appropriate training hours and that documentation has been stored in the training binders. Further reviews will be completed periodically by the Training Coordinator and Clinical Supervisor/Manager to ensure Staff are meeting their requirements. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
The facility failed to document a signed consent to release information for Transitional Living Facility clients to release information to the jail.
The jail requires a verbal confirmation of census, which includes client names and a headcount daily. This information is provided verbally over the phone. There were no signed consents to release information in client records #8, 9, 10, 11, 12, 13 and 14.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clients, upon admission to TLF will have a consent in their file to allow for correspondence regarding client information for all parties involved. All staff will be retrained and this will be enacted by 9/2/2019. The Clinical Supervisor and or Director will be responsible for conducting weekly chart audits to ensure that all consents are completed for all parties involved with that client. Further, all current clients, including those listed in the citation, will be required to sign a consent and all files will be updated by 9/1/2019. |
709.53(a) LICENSURE Complete Client Record
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
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Observations
The facility failed to document a complete client record including a record of service and progress notes in two of seven inpatient client records.
Client records were reviewed on June 26-28, 2019.
Client #6 was admitted on March 14, 2019. The last entry on the record of service was dated June 2, 2019 and the last progress note documented was dated June 7, 2019.
Client #7 was admitted on January 10, 2019. The last entry on the record of service was dated June 2, 2019 and the last progress note documented was dated June 2, 2019.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
All inpatient files will include notes based upon what activities/services the clients are receiving and they will be reviewed with the clients prior to entry into the file. Each activity that the client attends or participates in will be logged on the activity log and will be accompanied by a therapeutic note to discuss each activity and its relevance. All staff will be retrained and a new system of chart reviews will be in place by 9/1/2019. The Clinical Supervisor, Lead Therapist and a Chart Review Team will be responsible for checking charts weekly to ensure documentation is timely and appropriate. |
709.71(a)(1) LICENSURE Admission criteria
709.71. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(1) Criteria for admission.
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Observations
The facility failed to document a written plan providing for intake and admission which included the criteria for admission, guidelines for completion of residency and involuntary discharge/termination criteria.
The policy and procedure manual was reviewed on June 26-28, 2019. At the time of the inspection there was no intake and admission policy and procedures for the Transitional Living Facility activity.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A intake and admission policy will be created and implemented for Transitional Living Facility activities by 9/1/2019. This will be completed by our Policy Expert and all staff will be trained on this item by both the Policy Expert and Clinical Director/Supervisor by 9/1/2019. The Clinical Director will ensure that this policy has been created and implemented and will do routine audits of policies to ensure that this happens by 9/1/2019. |
709.72(a) LICENSURE Individual client record
709.72. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
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Observations
The facility failed to document a complete client record, which included activity notes in seven of seven Transitional Living Facility client records.
Client records were reviewed on June 26-28, 2019. Client records #8, 9, 10, 11, 12, 13 and 14 did not include any documentation of client involvement with the project. The only documentation present were slips regarding clients' exiting the building for various external activities.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Activity notes will be included within the TLF files by either the Case Manager or Intake Specialist to provide documentation regarding what services the client is being referred or admitted to and what services TPFO is providing the client. Also, this will be included in the updated TLF policy and will be in place by 9/1/2019. The Clinical Supervisor/Lead Therapist will be responsible for reviewing records on a consistency basis to ensure that all documentation is being provided to include the above mentioned services. |
709.73(a) LICENSURE Client Management Services
709.73. Client management services.
The transitional living facilities need not comply with 709.24 (a) (relating to treatment/rehabilitation management). The project's governing body shall instead adopt a written plan for the coordination of residential services which includes, but is not limited to:
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Observations
The facility failed to document a written plan for the coordination of residential Transitional Living Facility services, which included, defined target population, written procedures for the management of residential services for clients and written procedures for referrals outlining cooperation with other service providers.
The policy and procedure manual was reviewed June 26-28, 2019. At the time of the inspection, there was no documentation of a written plan for the coordination of Transitional Living Facility services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
TPFO's Policy Expert and Clinical Director will develop a written plan for the coordination of residential Transitional Living Facility service and will include a defined population, written procedures for the management of residential services for clients and written procedures for referrals outlining cooperation with other service providers. This will be completed by 9/1/2019. |